Bone marrow aspiration in a patient with systemic microsporidium

A 34-year-old female presented with several weeks of fever, fatigue, weight loss, abdominal pain and hemoptysis. PE revealed moderate pallor, RUQ pain, mild dyspnea, conjunctival injection and hepatomegaly. The CBC showed anemia, mild leukocytosis, hypoalbuminemia, hypertransaminasemia, presence of nucleated red blood cells. Microsporidium was found in BMA.

Late-onset Endophthalmitis Caused by Streptococcus Cristatus after Trabeculectomy

Purpose: To report a case of late-onset bleb-associated endophthalmitis caused by streptococcus cristatus (S. cristatus) after trabeculectomy.Case summary: A 59-year-old woman presented with left ocular pain and visual disturbance. She had undergone trabeculectomy of the left eye 2 years ago. At the initial visit, she was only able to count fingers from the left eye. Whitish thin bleb, conjunctival injection, and inflammation were observed in the left anterior chamber, and the fundus could not be visualized. Despite administering topical and systemic antibiotics, the chamber reaction worsened, and hypopyon and inflammatory membrane were noticed the next day. Vitrectomy with phacoemulsification and intravitreal antibiotic injection was performed, and the intravitreal antibiotic injections were repeated over the next two days. Bacterial culture of vitreous fluid showed a growth of S. cristatus 5 days after the surgery, and inflammation improved after 7 days. One month later, she was still only able to count fingers from the left eye, but there were no signs of endophthalmitis.Conclusions: Postoperative endophthalmitis after glaucoma filtering surgeries caused by S. cristatus has not been reported previously from Korea. To the best of our knowledge, this is the first Korean case of late-onset bleb-associated endophthalmitis caused by S. cristatus. If gram-positive cocci are grown in samples from the patients with endophthalmitis after trabeculectomy, resident oral microflora such as S. cristatus should be considered as the causative pathogen.

Spontaneous Closure of a Carotid-cavernous Fistula after Contrast-enhanced Orbit Computed Tomography

Purpose: We report a case of spontaneous closure of a carotid-cavernous fistula (CCF) after contrast-enhanced orbit computed tomography (CT).Case summary: A 80-year-old female was referred to our clinic under suspicion of chronic angle- closure glaucoma because of persistently high intraocular pressure commencing one month prior. Slit-lamp examination revealed a conjunctival injection and corkscrew-like vessel dilatation in the left eye, and a high intraocular pressure. Dilated fundus examination revealed central retinal vein occlusion in that eye. Contrast-enhanced orbit CT revealed a dilated, superior ophthalmic vein in the left orbit, and she was transferred to our department of neurosurgery for digital subtraction angiography (DSA); this is the gold standard imaging modality for the diagnosis of direct and indirect CCFs. DSA was performed two weeks after orbit CT; however, no CCF was visible. Thereafter, the conjunctival injection and the elevated intraocular pressure improved gradually over eight months. We suspect that the CCF closed spontaneously.Conclusions: Our case highlights the fact that a CCF can close spontaneously after contrast-enhanced orbit CT; ophthalmologists may wish to bear this in mind.

Acute Noninfectious Endophthalmitis after Removal of Silicone Oil and Posterior Capsulectomy in Proliferative Diabetic Retinopathy

Purpose: Here, we report a case of acute noninfectious endophthalmitis after removal of silicone oil (SO) and posterior capsulectomy in a patient with proliferative diabetic retinopathy.Case summary: SO removal and posterior capsulectomy were performed in a 61-year-old man who had undergone vitrectomy with combined cataract surgery, membrane peeling, laser photocoagulation, and SO injection to treat vitreous hemorrhage and tractional retinal detachment three months previously. The patient’s best-corrected visual acuity on the day after surgery was 20/50; it decreased to hand motion at five days after SO removal. Exudative membrane with hypopyon, anterior chamber cell (trace), and mild conjunctival injection were observed. The patient did not complain of ocular pain. Topical steroid was applied following a diagnosis of postoperative noninfectious endophthalmitis. The exudative membrane and hypopyon decreased after three days of treatment and had resolved completely after one month of treatment. The patient’s visual acuity improved to 20/50.Conclusions: Noninfectious endophthalmitis can develop after removal of SO and posterior capsulectomy. Topical steroid treatment is effective in such cases.

Toxic Keratoconjunctivitis from Coral Reef

A 25-year-old woman presented with right eye pain, lid edema, conjunctival injection and chemosis, and mild corneal epitheliopathy after exposure to fluid content from an aquarium coral reef. Topical moxifloxacin and prednisolone were started 4 times daily, with full clinical resolution after 2 weeks. Toxin-mediated keratoconjunctivitis may occur after exposure to zoanthid coral reef, particularly in aquarium enthusiasts. Topical corticosteroids in tandem with topical antibiotics appear to be effective in mild disease. However, in severe cases that exhibit corneal infiltrates and stromal thinning, close observation is warranted in case of possible keratolysis.

#25: Contemporaneous Evaluation of Kawasaki Disease and Multisystem Inflammatory Syndrome in Children Cases in Northern Virginia

Background Multisystem inflammatory syndrome in children (MIS-C) has a temporal association with SARS-coronavirus 2 (SARS-CoV-2) infection and can present similarly to Kawasaki disease (KD). After the Centers for Disease Control and Prevention issued a MIS-C case definition in May 2020, we implemented local diagnostic and management strategies to standardize the care for patients with MIS-C encouraging limited laboratory evaluation of non-toxic patients presenting with a febrile illness. We then sought to re-evaluate our diagnostic and management recommendations to ensure appropriate resource utilization for children with MIS-C and KD. Methods Patients with MIS-C and KD were identified via convenience sampling of Pediatric Infectious Diseases clinical records at Inova Children’s Hospital from May 1, 2020 to August 28, 2020. Manual chart review was done to extract clinical points of interest and the two cohorts were compared with descriptive statistics. Abdominal symptoms included pain, emesis, and diarrhea. Respiratory symptoms included shortness of breath, tachypnea, cough, and need for mechanical ventilation. Musculoskeletal symptoms included pain and edema. Neurologic symptoms included headache, dizziness, altered mental status, and irritability. Results 7 patients with KD and 14 patients with MIS-C were identified. No patients with KD had presenting hypotension and 9 patients with MIS-C had presenting hypotension (p < 0.01). Oral changes were seen in 5 patients with KD and 3 patients with MIS-C (p = 0.05). Conjunctival injection, rash, abdominal symptoms, musculoskeletal symptoms, and neurologic symptoms were seen in some patients with KD and MIS-C with no statistically significant occurrence of these symptoms between the two cohorts. The median initial absolute lymphocyte count was 2,860/µL in KD cases whereas it was 1,325/µL in MIS-C cases (p < 0.01). The median platelet count was 367,000/ µL in KD cases versus 193,000 in MIS-C cases (p = 0.03). The median initial C-reactive protein was 11.2 mg/dL in KD cases versus 23.2 mg/dL in MIS-C cases (p < 0.01). There was no statistically significant difference in the white blood cell count, erythrocyte sedimentation rate, alanine transaminase, B-natriuretic peptide, troponin I, or ferritin values between KD and MIS-C patients. Coronary artery dilation or prominence was seen in 4 patients with KD and in 8 patients with MIS-C (p > 0.99). There were no deaths. Conclusions Following national recognition of MIS-C we saw approximately 1 MIS-C case per week. Presenting hypotension, an absolute lymphocyte count less than 1400/µL, a platelet count less than 200,000/µL, and a CRP greater than 20 mg/dL best predicted MIS-C versus KD. The initial white blood cell count, alanine transaminase, erythrocyte sedimentation rate, B-natriuretic peptide, troponin I, ferritin, and initial coronary artery dilation did not readily distinguish KD from MIS-C. Thus, our diagnostic management recommending limited laboratory evaluation for non-toxic patients presenting with a febrile rash illness, fever and abdominal symptoms, or fever with conjunctival injection is reasonable.

POS1249 MULTISYSTEM INFLAMMATORY SYNDROME IN CHILDREN DURING THE COVID-19 PANDEMIC IN TURKEY: FIRST REPORT FROM THE EASTERN MEDITERRANEAN

Background:The severity of COVID-19 symptoms can range from mild to severe. Severe COVID-19 cases with excessive hyperinflammation have many overlap features with multisystem inflammatory syndrome in children (MIS-C).Objectives:We aimed to describe the typical clinical and laboratory features and treatment of children diagnosed with MIS-C and to understand the differences as compared to severe/critical pediatric cases with COVID-19 in an eastern Mediterranean country.Methods:Children (aged <18 years) who diagnosed with MIS-C and severe/critical pediatric cases with COVID-19, were admitted to hospital between 26 March and 3 November 2020 were enrolled in the study.Results:A total of 52 patients, 22 patients diagnosed with COVID-19 with severe/critical disease course and 30 patients diagnosed with MIS-C. Although severe COVID-19 cases and cases with MIS-C share many clinical and laboratory features, MIS-C cases had longer fever duration and higher rate of the existence of rash, conjunctival injection, peripheral edema, abdominal pain, altered mental status, and myalgia than in severe cases (p<0.001 for each). Of all, 53.3% of MIS-C cases had the evidence of myocardial involvement as compared to severe cases (27.2%). Additionally, C-reactive protein (CRP) and white blood cell (WBC) are the independent predictors for the diagnosis of MIS-C, particularly in the existence of conjunctival injection and rash. Corticosteroids, intravenous immunoglobulin (IVIG), and biologic immunomodulatory treatments were mainly used in MIS-C cases rather than cases with severe disease course. There were only 3 deaths among 52 patients, one of whom had Burkitt lymphoma and the two cases with severe COVID-19 of late referral.Conclusion:Differences between clinical presentations, acute phase responses, organ involvements, and management strategies indicate that MIS-C might be a distinct immunopathogenic disease as compared to pediatric COVID-19. Conjunctival injection and higher CRP and low WBC count seem good diagnostic parameters for MIS-C cases.Disclosure of Interests:None declared

Mycoplasma pneumoniae-associated mucositis

A 9-year-old boy presented to the emergency department of a paediatric hospital with non-painful lesions on his lips and inside his mouth, associated with lip swelling. On examination, his oral mucosa and lips showed numerous blisters with yellowish serofibrinous content and lip oedema. An eye examination revealed bilateral conjunctival injection. Genitalia was unaffected and no other skin lesions were found. He was on day 4 of clarithromycin prescribed for atypical pneumonia caused by Mycoplasma pneumoniae. The patient was diagnosed with M. pneumoniae-associated mucositis and was started on topical treatment with fusidic acid and betamethasone, with gradual improvement of the oral lesions.